What is the recommended treatment for an adult patient with no prior glaucoma treatment presenting with high intraocular pressure (IOP) or signs of glaucoma?

Treatment for High IOP or Glaucoma Signs

For adults presenting with high IOP or signs of glaucoma, initiate treatment with a prostaglandin analog as first-line therapy, targeting at least 20% IOP reduction from baseline, with more aggressive targets (25% or greater reduction) for patients with multiple risk factors or confirmed glaucomatous damage. 1, 2

Risk Stratification Determines Treatment Urgency

High-risk patients requiring immediate treatment:

• Baseline IOP ≥26 mmHg combined with thin central corneal thickness (CCT ≤555 μm) carries a 36% risk of optic nerve damage and mandates treatment 1
• Any evidence of optic nerve deterioration, retinal nerve fiber layer (RNFL) loss, or visual field changes consistent with glaucoma indicates conversion to primary open-angle glaucoma (POAG) requiring immediate treatment 3
• Presence of disc hemorrhages, large cup-to-disc ratio, or rapid progression warrants aggressive IOP lowering 1, 2

Lower-risk patients who may be monitored without immediate treatment:

• IOP <24 mmHg with thick CCT (>588 μm) carries only 2% risk of optic nerve damage 1
• Absence of other risk factors (younger age, no family history, no structural changes) supports observation 3

Additional risk factors that increase treatment priority: 1

• Older age
• Family history of glaucoma
• African ancestry or Latino/Hispanic ethnicity
• Type 2 diabetes mellitus
• Myopia
• Lower ocular perfusion pressure or low systolic/diastolic blood pressure
• High pattern standard deviation on visual field testing

Target IOP Goals

Set initial target IOP at 20-25% below baseline pretreatment levels: 2

• For IOP of 26 mmHg, target approximately 21 mmHg or lower 1
• For confirmed glaucomatous damage, aim for 25% or greater reduction to slow progression by 45% 2, 4
• For severe disease, target 10-12 mmHg; moderate disease 12-15 mmHg; mild disease 15-17 mmHg 5

The Ocular Hypertension Treatment Study demonstrated that treatment reducing IOP by 20% decreased 5-year risk of developing POAG from 9.5% to 4.4%. 3, 1

First-Line Medical Therapy

Prostaglandin analogs are the preferred initial medication: 1, 2, 6

• Provide 6-8 mmHg IOP reduction (20-35% decrease) from baseline pressures of 24-25 mmHg 2, 6
• Once-daily dosing improves compliance 6
• Most effective single agents with favorable tolerability profile 2, 6
• FDA-approved latanoprost specifically indicated for elevated IOP in open-angle glaucoma or ocular hypertension 7

Alternative first-line options if prostaglandin analogs are contraindicated or not tolerated: 1

• Topical beta-blockers (timolol is FDA-approved for elevated IOP in ocular hypertension or open-angle glaucoma) 8
• Alpha-2 adrenergic agonists
• Laser trabeculoplasty

Laser trabeculoplasty should be considered when: 3

• Medication nonadherence is a concern
• Cost or convenience factors limit medication use
• Side effects or risks of medication are problematic

Escalation Strategy

If target IOP is not achieved with monotherapy: 2

• Switch to a different medication class if no response to first agent
• Add a second agent if partial response to first medication
• Do not continue the first medication if there is no IOP response 2

Adjunctive agents for inadequate monotherapy response: 9

• Alpha-adrenoceptor agonists
• Carbonic anhydrase inhibitors
• These provide additional IOP reduction for patients not controlled on single-agent therapy 9

Essential Monitoring Requirements

Long-term monitoring is mandatory regardless of whether treatment is initiated: 3, 1

• Serial optic nerve head and RNFL imaging 1
• Regular visual field testing 1
• Periodic IOP measurements 1

Reassess target IOP if progression occurs despite achieving initial target: 2

• Target IOP is an estimate requiring periodic reassessment, not a fixed endpoint 2
• Lower the target further if optic nerve deterioration, RNFL loss, or visual field progression is documented 2, 6
• Compare serial optic nerve head appearance, quantitative disc assessments, and RNFL measurements to validate target IOP adequacy 2

Critical Decision Points

The decision to treat versus observe must be discussed with the patient, including: 3

• Number and severity of risk factors present
• Prognosis and management plan
• Likelihood that therapy will be long-term
• Risks, side effects, and expense of treatment

Common pitfall to avoid: Do not delay treatment in high-risk patients (IOP ≥26 mmHg with thin CCT, multiple risk factors, or any structural/functional damage) while attempting observation, as 90-95% of ocular hypertension patients do not develop glaucoma over 5 years, but the high-risk subset has substantially elevated risk requiring intervention. 3, 1